Reproductive Health: The Biggest Casualty of the Ebola Epidemic?

Childbirth is a messy, bloody, production. And because pregnancy complications often manifest as classic Ebola symptoms—bleeding, fever, nausea – health workers (when available) may fear contracting the disease and deny women maternity services. Preliminary data from Guinea, Liberia, and Sierra Leone suggest substantial declines in maternity hospital admissions since the onset of the epidemic, as routine health services have been severely disrupted, if not altogether halted. Interruptions to antenatal care and family planning services have stranded women, increasing their vulnerability to pregnancy complications, malaria, anemia, unintended pregnancies, and death. Prior to the outbreak, maternal mortality rates (MMR) were declining in the region as more women sought to deliver in health facilities, yet Ebola threatens to reverse such progress in improving women’s health outcomes and care-seeking behavior.

Ebola is all but a death sentence for pregnant women and their babies, with reported fatality rates as high as 96 percent for mothers and 100 percent for their infants [1]. A pregnant woman’s blood, amniotic fluid, placenta, fetus, and sweat are all highly infectious, rendering deliveries extremely risky, even with use of full personal protective equipment (PPE). Thus, health workers may find themselves facing an ethical dilemma – risk exposure to Ebola by treating pregnant women who may or may not be infected, depleting limited PPE supplies, or avoid such risk altogether by not intervening, seeing as death is likely in either course of action. Many health workers appear to subscribe to the latter.

The New Yorker reported in an article based on interviews with Sierra Leonean nurses that an unofficial protocol has emerged among health workers: deny infected pregnant women access to Ebola wards, or if entry is permitted, triage them last [2]. In Liberia, rumors are rife that among the health workers who became infected with Ebola, most contracted the disease as a result of caring for pregnant women; after all, this is how American doctor Rick Sacra, who was equipped with full PPE, became infected in August 2014.

In response to such heightened risks and fears, health workers have abandoned their posts, and maternity wards and other health facilities have closed. Even when services are available, pregnant women may fear infection at the hands of providers, and thus avoid health facilities, opting instead to deliver at home. Moreover, distrust in the health system has become widespread, and pregnant women who do seek treatment may be ostracized and face stigma from family and friends who fear exposure from health facilities – the same facilities once regarded and promoted as the recommended and standard course for delivery.

The United Nations Population Fund (UNFPA) estimates that more than 120,000 of the 800,000 women in Guinea, Liberia, and Sierra Leone who will give birth over the next year could die as a result of complications such as obstructed labor or infection if emergency obstetric care is not available [3]. This translates to nearly 330 women each day. Maternal mortality rates in West Africa currently rank among the world’s highest (pre-Ebola), and failure to intervene now may result in a 20-fold rate increase, or 15 percent (vs. 0.75 percent currently). Not included in these figures are the thousands of other women who may develop agonizing medical conditions such as obstetric fistula. Or the estimated 1.2 million women of childbearing age for whom family planning services are now out of reach.

So what exactly is needed to prevent further increases in maternal morbidity and mortality, and by extension, a growing orphan population? What can be done to ensure that women in West Africa in need of reproductive health care have access to it?

According to the governments and agencies coordinating the response efforts, the answer entails training national and international midwives; deploying equipment, drugs, and supplies; raising awareness and mobilizing communities; and building the capacity of national health professionals. Together, the strategies can increase access to essential normal and emergency obstetric and neonatal services for women and newborns in Guinea, Liberia, and Sierra Leone.

Ensuring access, however, may not be enough. Once services are restored, it will also be important to generate demand among women for the services and rebuild their trust and confidence in health workers. The need to routinely test for Ebola among pregnant women, allowing for appropriate triage and allocation of limited PPE, is also recognized as a priority. So too are efforts to prevent infection among pregnant women by adhering to standard infection prevention and control (IPC) practices such as the rapid identification and isolation of suspect Ebola cases, proper use of PPE among health workers, secure disposal of infected waste, and safe funerary practices. Throughout the process, efforts must also be made to collect accurate data to monitor progress and inform decision-making.

In parallel with the ongoing response efforts to combat Ebola, urgently restoring maternal and reproductive health services across the region is imperative to avoid further reversing the earlier gains made. Otherwise, reproductive health may be the biggest casualty of the Ebola epidemic yet.